MRCOG PART II ESSAY 278 - ERPC

A healthy 17 year old woman complains of severe abdominal pain and heavy vaginal bleeding 3 hours after surgical evacuation of a 10 weeks missed miscarriage. (a) Discuss your initial management [12 marks]. (b) Discuss your intra-operative management of uterine perforation during evacuation of retained products of conception [8 marks].

a.I will assess her quickly, checking her airway and breathing is s adequate, and check her  BP pulse, temperature and oxygen saturation. If there is cardiorespiratory or haemodynamic compromise I will call for immediate help with resuscitation.

Otherwise I will take a brief history asking about risk factors for uterine perforation eg past caesarean section, and symptoms of uterine perforation eg severe, worsening pelvic pain, shoulder tip pain. I will ask about symptoms of haemorrhage eg lightheadedness, palpitation and thirst.

I will examine her looking for slow capillary refill, cold clammy extremities, tachycardia, hypotension, tachypnoea and pallor which would suggest severe intraabdominal haemorrhage.

I will examine the abdomen for distension, shifting dullness, and peritonism  and examine vaginally for the extent of blood loss.

If she is haemodynamically stable with minimal symptoms and no abdominal signs of haemorrhage I will arrange an urgent pelvic and abdominal ultrasound to exclude free fluid, suggestive of bleeding.

I will Ensure she has a large bore canula, and take blood for FBC, group and crossmatch four units, U&Es, LFTs. In the presence of haemodynamic compromise I will carry out a haemocue to help decide on blood transfusion , and request for clotting profile.

I will inform the on-call consultant gynaecologist, anaesthetist and emergency theatre team of the need for urgent surgery.

I will explain my suspicion of uterine perforation and obtain informed consent for laparosopy and/or laparotomy, repair of uterine perforation and completion of evacuation of retained products of conception. I will warn her of common complications eg shoulder tip pain abdominal discomfort and serious complications eg bowel, bladder or blood vessel injury requiring repair. I warn her of the risk of requiring a hysterectomy if there is extensive uterine damage. I will obtain her consent for blood transfusion and cell salvage.

Together with the gynaecology consultant on-call I will proceed to diagnostic laparoscopy if she is haemodynamically stable, but if there is haemodynamic instability I will initiate blood transfusion and proceed to laparotomy.

B.I will stop the procedure, inform the anaesthetist and call the gynaecology consultant on-call to theatre, and proceed to diagnostic laparoscopy. In the presence of haemodynamic instability I will proceed to urgent laparotomy. I will send blood for FBC, grp and crossmatch 4 units, U&Es, LFTs clotting if haemorrhage is severe.

At laparoscopy or laparotomy I will examine the uterus for perforation and bleeding. In the event of a small non-bleeding perforation I will offer antibiotics and manage her conservatively. if there is a larger perforation or tears I will proceed to repair, laparoscopically if the gynaecology consultant has the skill, or laparotomy in the absence of this, or complex tears, technical difficulty or haemodynamic instability of the patient. I will offer perioperative antibiotics if laparotomy is required.

I will also examine carefully for bowel, blood vessel , urinary tract and other adjacent injuries.

I call the general surgeons to assist with repair of bowel injuries, vascular surgeons for vascular injuries and urologists for urinary tract injuries.

I will complete evacuation under abdominal vision. I will ensure mechanical boots are used to prevent DVT.

I will arrange an ITU bed if haemorrhage was massive, document procedures, findings and outcome clearly and carry out a VTE risk assessment and prescribe LMWH in the absence of contraindications.

Initial assessment begins whether  she responds to verbal command or not, assess her adequacy of airway,  breathing & circulation.I will check her pulse, blood pressure , temperature & oxygen saturation.If quick primary survey is suggestive of massive hemaorrhage as evident by tachycardia, hypotension, tachypnea, I wil call for help & resucitation will begin promptly.

If she is hemaodynamically stable, brief history will be taken to ask about severity of pain, location, intensity & radiation to shoulder pointing towards peritonitis as a result of intraabdominal bleed. her symptoms of palpitation, feeling thirst , lightheadiness also suggest hemorrhagic shock. Her general appearance such as pallor, cold calmmy extremities, difficulty to breath also give me an idea of extent of bleed.

I will do abdominal examination to look for distention, fluid shift & tenderness. I will assess pad followed by speculum examination to see clots & severity of bleeding. I will quickly glance at fluid input /output chart, if catheter is in will check urine output.

I will ensure that her IV line is maintained & depending upon severity I will pass another14 guage cannulae & send 30ml blood specimen for CBC, cross match 4 units of blood, liver function test, creatinine, electrolytes, otherwise I will send blood for CBC, group & svae blood in hemodynamically stable condition. i will consult with hematologist for advise for blood transfusion products after reviewing her wishes for blood products.

I will inform on call Consultant gynecologist, consultant anaesthetist & theatre staff to be prepared for laparoscopy , possible laparotomy.

I will discuss with woman about suspicious of uterine perforation & my management plan with laparoscopy , possible laparotomy. I will explain the procedure of laparoscopy with associtaed serious complications of bladder, bowel, vessels injury & most common symptoms such as shoulder pain post operatively. i will explain that if there is extensive tear & uterine damage not repairable by laparoscopy, I will proceed with laparotomy. I will warn her about rare but serious consequences such as hystrectomy. I will ask her views about blood transfusion & its products If need arise perioperatively. I will take informed consent.

In stable condition, I will proceed with laparoscopy along with consultant gynecologist. In hemodynamically instability, I will transfuse blood to make her stable before proceeding to theatre.

B- I will stop the procedure, I will inform anaesthetist, theatre staff & call consultant gynecologist on call.

 I will proceed to diagnostic/therapeutic laparoscopy if she is hemodynamically stable. In unstable condition, I will proceed to lapartomy & will initiate resucitation simultaneously, ask help from anesthetist & theatre nusre, send blood for FBC, 4 units of cross match blood, electrolytes, liver function tests, clotting profile in massive haemorrhage.

While performing laparoscopy or laparotomy, I will inspect the abdomen for any blood if present, inspect the uterus for tear, extension of tear & its location. If perforation site is not bleeding, small in size, will manage conservatively with perioperative antibiotics.In large perforation will repair laroscopically depending on skill of consultant gynecologist.

if active bleeding, big perforation, extensive tear, proceed to laparotomy. If any associated bladder, bowel or ureteriuc injury is suspected call surgeon, urologist for consultation.

I will complete evacuation under direct vision & oxytocin will be given.

She is at risk of VTE due to hemorrhage , I will start TED along with LMWH as thromboprophylaxis.

I will complete my theatre notes meticulously, documented all events & clinical incident form to be filled out.

As soon as woman is able to communicate & comprehend , early visit should take place to explain all events &  woman & her family will be given an apportunity to ask questions. I will assess her needs for future contraception.

I will inform her GP & arrange follow up visits.

A)

The probable causes are uterine perforation or incomplete evacuation. If the uterus has been perforated there is risk of visceral injury.

Attention is paid towards her haemodynamic stability. Pulse and Blood pressure are recorded. Overt bleeding is noted. Bleeding severe enough to cause hypotension and tachycardia prompt immediate resuscitative measures. Help is called from senior gynaecologist, anaesthetist, senior  midwife and haematologist.

 Air way checked and breathing assessed. 100% oxygen is given by facial mask at the rate of 10 to 15 l/min. Venous access is obtained with 2 wide bore cannulae. Blood is sent for FBC, U &E, LFT, clotting screen and for crossmatch of at least 4 units. Blood for culture & sensitivity as she is at risk of sepsis. Fluid resuscitation is carried out with crystalloids, colloids . O rh neg blood is given while waiting for the crossmatched blood.

If she is stable history is taken regarding the nature of pain, constant pain which gets worse on movement indicates peritoneal irritation. Coliky pain suggests uterine contractions. Abdominal examination is performed to detect abdominal distension, tenderness and guarding. Abdomen is auscultated for bowel sounds. Uterine enlargement suggest haematometra.  Speculum examination is done to identify amount of bleeding, and for the persence of products of conception in the os.

Pelvic examination is done to note the uterine size and cervical excitation. 

If the woman is haemodynamically stable, and bleeding is settling, and no suspicion of uterine perforation , analgesia and blood transfusion are appropriate.  Uterotonics like ergometrine aid in control of bleeding. 

But persistent bleeding  with haemodynamic compromise prompt surgical treatment after resuscitation.

B)

Woman should be managed in association with a senior anaesthetist and general surgeons .

Laparoscopy should be performed to assess the uterine perforation. If no evidence of perforation during laparoscopy, evacuation of  uterus should be completed under laparoscopic vision.

If the uterus is perforated,  there is risk of missing visceral injury during during laparoscopy, then laparotomy is mandatory with assistance from general surgical colleagues to carry out bowel resection +/- colostomy if bowel is injured. 

If the woman's condition permits, she should be explained about the possible surgical procedures like hysterectomy, bowel resection and colostomy. Written consent is taken. 

Incident form should be filled. Family members are informed about the reasons for further surgery as soon as possible. 

A ] The  management of this patient depends on the condition of the patient ,if she is haemodynamically stable or unstable .This patient might have had incomplete evacuation of the uterus or might have perforated her uterus during evacuation .If she would have perforated  her uterus there is risk of visceral injury .if the patient is haemodynamically unstable resuscitate the patient . call for help by the senior obstretician , anaesthetist, haemotologist . inform them about the situation and keep the theatre informed that the patient might need further procedure depending on the diagnosis. check the patients pulse and BP .Resuscitate the patient by obtaining IV access and collect blood for FBC , group and save , clotting profile .give IV colloid or crystalloid .give fascial oxygen in case of decreased oxygen saturation until oxygen saturation level is maintained .In case of massive haemorrhage give O negative blood until group specific blood is available .in need of blood products consult with the haematologist .maintain input and out put chart . assess the amount of  blood loss .once the patient is stable take  history about the site of pain , severity , any aggrevating and relieving factors . ask her if the pain increases on movement , this must be due to peritonial irritation .or any colick pain which might be due to uterine contractions  . review her operative notes to see  if any complication at the time of the procedure and general condition of the patient after the procedure . Examination - Temperature , Pulse, BP, BMI .abdominal examination for tenderness, rebound tenderness, bowel sounds .speculam examination to see cervical status , any cervical trauma , any retained products in the cervical os , and any active bleeding . vaginal examination for size of uterus ,tenderness, Cervical excitation tenderness, and fullness in pouch of doughlass. Investigation -Blood for FBC , Group and save , LFT, RFT and coagulation profile .urine analysis . By this time if bleeding settle and no risk of perforation and  no any more retained products of conception  manage consevatively by analgesics and blood transfution  if needed . if patient has minimal bleeding give uterotonics for uterine contraction . if patient has persistant bleeding and suspicion of perforation  manage surgically .

B] call for help by the senior obstretician , haematologist, and general surgeon . inform them about the perforation and need for further surgery  .  inform the anaesthetist .  This patient need laparoscopy to confirm the perforation , but visceral injury might be missed . if uterine perforation is confirmed laparotomy is done and uterus is repaired depending on the amount of damage . if bowel is damaged bowel resection and end to end anastomosis  and colostomy is done by the surgeon .in case of unrepairable damage and massive intractable bleeding hysterectomy is done . post operative the patient is cared in HDU . assess for the need for thromboprophylaxis , as there is bleeding and major surgery  done . encourage early ambulation ,and avoid dehydration .provide post operative analgesics and antibiotics . debrieff about the situation to the patient and her relatives . detail documentation must be done . fill in risk incident form . in case colostomy is done inform the patient and her relatives for the need of further  surgery in future .adequate post operative  psychological councelling as patient is at risk of post traumatic stress disorder .provide information leaflet and contact detail of support group . post operative follow up appointment after 6 weeks along with the surgeon .offer contraceptive advice .

a).Severe abdominal pain and heavy bleeding point to possibility of incomplete evacuation or  uterine perforation . Initial assessment of hemodynamics done .Call for senior obstetrician anaesthetist ,midwife. Inform consultant obstetrician , anaesthetist as possible need to return to theatre .  If hemodynamically unstable, pulse >100 ,Systolic BP < 90 -100, initiate ABC of resuscitation. Nasal oxygen 15 litres /min, secure airway.

Start two intravenous lines 14 G, (brown,orange). Take 20 ml blood for full blood count , urea electrolytes, liver function test, cross matching blood, ABG . Start fluid resusucitation, 2litres crystalloid hartmann solution. Colloids can be given upto 1.-2 litres till blood arrives. Inform blood bank arrange at least 4-6 packed cells and fresh frozen plasma accordingly if massive hemorrhage. Give uncrossed O negative blood if delay. Keep woman warm. One member of team to note details and monitor pulse ,bp, urine output , fluid balance.. Start uterotonics oxytocin to arrest bleeding .

If hemodynamicaly stable ask history of amount of bleeding. Examine pulse ,bp pallor. Abdominal examination for tenderness guarding rigidity, bowel sounds. Speculum examination for  products of conception, ongoing heavy bleeding done .Do pelvic exam for adnexal tenderness uterine size. Further management depends on hemodynamic stability, ongoing bleeding possibility of uterine and bowel perforation.

Only if  stable arrange for urgent ultrasound for retained products and chest x ray abdominal x ray for free gas. If bleeding stopped and stable give broad spectrum antibiotic , blood transfusion ,analgesics and observe  per MEOWS chart.

If unstable , bleeding continues arrange for return to theatre. Inform senior surgical colleagues about need for laparoscopy/laparotomy if uterine perforation and suspected bowel injury. If woman conscious take informed consent , discuss need for evacuation of retained products under laparoscopy and need for laparotomy for bowel injury repair /colostomy,/hysterectomy  as per findings.

b).During a procedure if uterine perforation is suspected ,cannula going in without resisitance omentum seen in cannula tip, stop procedure immediately. Examine cannula tip . Inform consultant immediately. Inform anaesthetist as need for prolonging anaesthesia and need for laparoscopy/laparotomy. Inform scrub nurse as necessary instruements to be arranged.

 If woman under general anaesthesia proceed as in best interest . Take blood for cross matching , RFT LFT

 Laparoscopy done if patient stable, expertise  equipments available. If no  perforation complete procedure under laparoscopy. If small uterine perforation , decision on conservative management or repair at senior level. Involve surgeons in decisions as laparoscopy may miss bowel injury. Proceed with laparotomy if unstable or bowel injury and uterine perforation repair , bowel repair ,colostomy done with surgeons .Abdominal drain kept.

Postoperative care in HDU . Debriefing done for patient , family/ partner regarding complications and procedures performed . Thromboprophylaxis by early mobilisation ,avoiding dehydration. Heparin as per unit  protocol. Broad  spectrum antibiotics given. Follow up with surgeons if colostomy done with advice about stoma care. Incident report to be filled if return to OT, uterine bowel perforation .Discuss follow up about future pregnancies, contraception. Inform GP. Details of support group like miscarriage association given.

A healthy 17 year old woman complains of severe abdominal pain and heavy vaginal bleeding 3 hours after surgical evacuation of a 10 weeks missed miscarriage. (a) Discuss your initial management [12 marks]. (b) Discuss your intra-operative management of uterine perforation during evacuation of retained products of conception [8 marks].

most likely diagnosis is uterine perforation. if woman is heamodynamically stable , i will ask about nature of abdominal pain , site , radiation. i will ask about amount of bleeding , any blood clots . iwill ask about giddiness , dizziness and headache that point towards significant blood loss .if she is not heamodynamically stable , i will start resuscitation.i  will activate major hemorrahge protocol  . i will  call  consultant gynaecologist , consultant anesthetist  and senior nurse .i will inform haematologist . one member of team will record the events and time . i will assess the airway , start 10-15 L of oxygen via facemask , two wide bore cannulas are inserted and blood collected for FBC , U&E , liver function test , group , crossmatch 4 units of blood. coagulation screen may be needed. BP , Pulse , temp  monitoring started simultanoesly. O-ve blood can be started in event of life threatening bleeding. 

after consent , emergency laprotomy is performed  in haemodynamically unstable woman to look for uterine perforation and extent of viseral , vascular injuries . consultant gynaecologist or senior trainee under consultant supervision will perform the laprotomy . vascular surgeon, urologist  and generalsurgeon will be called for help depending upon site of injury.

uterine perforation reparied . intraoperative antibiotics are given to prevent infection. if woman is stable ,laproscopy is performed , if site of perforation is small ,  not bleeding , can be managed conservatively . woman and family members are kept informed at all stages of care.

B ;    I Will immediately stop further attempts at evacuation to prevent further viseral injury  and informed anesthetist . i will call consultant gynaecologist , senior nurse . laproscopy will be performed to confirm and locate the site of perforation. if not perforation is found , evacuation is completed under direct vision from laproscope. if perforation found , blood group , cross match sent and resusciation started . site , size of perforation and viseral injury identified , vascular / general surgeons /urologists called depending upon site of injury. laprotomy will be perfomed under general anesthesia.

if there is  perforation with  dilator , there is no bleeding , no viseral/vascular injury , it can be managed  expectantly .

broad spectrum antibiotics are given . clear documentation of events and procedures perfomed ,is mandatory. incident reporting done. 

Ans a)Most likely diagnosis  is uterine perforation, however incomplete evacuation can also lead to uterine atony and bleeding. I will check her airway, breathing, pulse and blood pressure. Tachypnoea, tachycardia and hypotension ,pallor suggest excessive blood loss. In that case,  I will  call for help and involve consultant gynaecologist, anaesthetist, haematologist, blood bank and laboratory. Double  intravenous (IV) will be maintained with large bore  cannulae.Blood will sent for full blood count, for heamatocrit and platelets. Urea and electrolytes and liver function tests. Clotting screen as there is risk of coagulopathy with heavy bleeding.I will start oxytocic infusion, to ensure uterine contraction. Warmed IV fluids started, crytalloids and then colloids till availability of blood. O negative blood can be given in case of delay.  Broad spectrum IV antibiotics started, after checking for allergies from notes. . I will do abdominal examination. There might be tenderness, guarding , rigidity, distention and absent  bowel sounds if uterine perforation , visceral  trauma and bleeding .I will do her  bimanual vaginal examination to assess degree of blood loss, uterine tenderness( perforation), uterine atony ( if incomplete evacuation ). Bedside ultrasound to look for any free fluid (blood) in pelvis .  Vigilent monitoring of BP, Pulse, respiratory rate, will be done and intake, output record  maintained to assess hemodynamic status. If her vitals are stable and bleeding  is controlled, she can be observed and managed conservatively. If evidence of perforation and uncontrolled bleeding, she will be prepared for urgent laparoscopy/ laparotomy.Condition will be explained to patient and her partner sensitively. They will be told about need for surgery to investigate the injury and repairs if needed. I ll inform about the risks related to procedures. Informed consent will taken/rechecked from the notes. Surgical team will be involved if injury to abdominal organs is suspected or encountered.  

B: If there is  perforation during evacuation, I will abandon the procedure, and inform consultant gynaecologist,  anaesthetist, scrub nurse, regarding need for possible laparoscopy/ laparotomy  . If heavy bleeding blood bank, hematologist, Intensive care will be involved. If patient is conscious, I will ask about pain in abdomen and shoulder ( suggest intra abdominal bleeding) and examine for abdominal tenderness and bowel sounds. Ultrasound can be used  to look for signs of perforation and bleeding. I will inform her( if she is conscious ) and her partner about the incident with sensitivity, and about need for laparoscopy and/ or laparotomy to investigate the injury and any repairs. Informed consent will be taken. Risks associated with these procedures explained, like organ damage ,bleeding and later on hernia. I will maintain another IV line with 14 guage cannula. Start  IV oxytocics for uterine contraction. Warmed IV fluids, O negative if heavy bleeding , till availability of blood. Broad spectrum  IV antibiotics started as there is risk of infection.She will be catheterized to avoid  trauma during surgery and for intake output record. If she is haemodynamically stable, laparoscopy will be done by experienced operator to explore and if possible repair. In case of heavy bleeding /extensive injury , laparotomy will be performed.  If trauma to other abdominal organs, vessels, then surgical team will be involved. Repair done, may need colostomy if gut involved.  Findings and procedure will be documented  in detail. Shifted to and monitored in HDU. Thrombo prophylaxis , with early mobilization, hydration and TED stockings . Heparin given after risk assessment. Incident form will be filled out and later on incident should be investigated. Follow up and debriefing of patient is arranged. Appropriate follow up with surgical team arranged if required. She will be counseled regarding contraception and implications for future pregnancies.  If she needs psychological support and counselling, she will be referred.  Information leaflets and contact details of support groups given .